Contraceptive requests by under-16s

The law allows GPs to use their discretion in these cases. By MDU medico-legal adviser Dr Brigid Simpson

More than a quarter of young people admit that they are sexually active before they reach 16,1 so many GPs will have faced the dilemma of giving medical advice and treatment to under-16s without their parents’ knowledge.

The MDU receives 10–20 calls a week from doctors who are seeking ethical or legal advice about treating teenagers and GPs must judge all requests from under-16s for advice about contraception on their individual merits.

Legal responsibilities
Under section eight of the 1969 Family Law Reform Act, the legal age of consent for medical treatment in the UK is 16.However, under-16s may be able to give consent if they understand the nature, purpose and hazards of a treatment.

The question of the rights of children under 16 years of age to consent to treatment on their own behalf was considered by the House of Lords in 1985, in the case of Gillick v West Norfolk and Wisbech AHA. The majority opinion in the House of Lords was that doctors should have the discretion to act according to their view of what is in the patient’s best interests.

The Law Lords said that a doctor should seek to persuade the patient to tell their parents they are seeking advice about contraception and the nature of the advice they receive. Lord Fraser concluded that a doctor would be justified in proceeding without the parent’s authority or knowledge if:

  • The teenager understands the doctor’s advice.
  • The doctor cannot persuade the teenager to inform her parents or allow the doctor to inform them that she is seeking advice about contraception.
  • The teenager is likely to begin having, or continue to have, sexual intercourse with or without contraception.
  • The teenager’s physical or mental health, or both, would suffer unless she received advice about contraception.
  • It is in the teenager’s best interests for the doctor to provide advice, treatment or both, without parental consent.

Other guidance
The GMC states that GPs must assess a child’s capacity to give or refuse consent before providing treatment.2 In general, a competent child will be able to understand the nature, the purpose and the possible consequences of the proposed investigation or treatment, as well as the consequences of
non-treatment (paragraph 23).

In its guidance on treating under-18s ,3 the GMC adds that doctors can provide contraception to under-16s without parental knowledge or authority in certain circumstances. The child must be able to understand the advice, cannot be persuaded to tell their parents or allow you to tell them and is likely to engage in sexual activity without contraception (paragraphs 70 and 71).

The MDU advises that it is in children’s best interests to be able to seek advice from their GPs about sensitive issues and know that they will be treated in confidence.

GPs advising under-16s on contraception need to decide, on a case-by-case basis, whether the child is mature enough to consent to treatment on their own behalf. Children under 16 can consent to treatment only if they fully understand its nature, purpose and hazards. That ability will vary with age, the child and the nature of the treatment. The doctor should discuss with the child the issue of involving their parents. If you are in any doubt, it is advisable to seek advice from your medical defence organisation before proceeding.

CASE STUDY
A 15-year-old girl came to see her GP in tears. She had been to a party the previous evening, drunk too much and had unprotected sex with her boyfriend. She asked to be prescribed emergency contraception and inquired about taking the oral contraceptive pill, but was anxious that her parents should not be told. The GP telephoned the MDU because he had reservations about prescribing contraception to a girl of this age, particularly without her parents’ knowledge.

In the case above, the MDU referred the GP to GMC guidance ,4 which states that if a doctor has a moral objection to giving advice ‘you must explain this to the patient and tell them they have the right to see another doctor’ (paragraph 8).

In its 0–18s guidance,3 the GMC adds that where doctors are unable to offer advice to a child because of conflicts with their moral or religious beliefs, they need to be aware that children may have difficulty in making other arrangements themselves, so the doctor must ensure arrangements are made for the child to see a suitably qualified colleague (paragraph 72).

In this case, if the doctor decided to advise the child, he should then decide whether she had the intelligence and maturity to understand the nature, purpose, benefits and risks of the treatment, as well as any alternatives and the risk of going untreated. If so, her consent alone may be valid and she would also have the capacity to give or withhold consent to disclosure of confidential information. The steps taken to establish her capacity to consent should be documented in the notes.

The GP was advised to take every reasonable step to persuade her to involve her parents. If she refused, the GP could accept her consent as valid if he established that she had capacity. If the patient wanted to involve her parents, the GP could give them a full explanation. If she did not give an indication either way, the GP would have to ask her permission before disclosing any information to the parents. The GP would also need to consider whether there was any evidence of an abusive relationship between the patient and her partner and take appropriate action if necessary.

The case discussed here is fictitious, but it is based on cases from the MDU’s files. Doctors with specific concerns are advised to contact their medical defence organisation for advice.

- Dr Brigid Simpson is a medico-legal adviser at the Medical Defence Union

References
1. Wellings K, Nanchahal K, Macdowall W et al. Sexual behaviour in Britain: early heterosexual experience. Lancet 2001; 358: 1843-50.
2. Seeking patients’ consent: the ethical considerations. GMC, London, 1998.
3. 0–18 years: guidance for all doctors. GMC, London, 2007.
4. Good Medical Practice. GMC, London, 2006.

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